A negative outcome from a safety incident can often be wrongly blamed on the single person whose role was to provide just one of many safeguards. But there are usually a multitude of events and circumstances that lead to a negative outcome, rather than the actions of just one person in a process.

This way of thinking means that vulnerabilities of other, perhaps more critical, safeguards may not be identified, studied and improved, allowing similar incidents to occur repeatedly. In some cases, the people most likely to be blamed are the most junior or inexperienced, often near the bottom of a hierarchical system. However, these people might well have recognised that the situation had a high risk of leading to a negative outcome, but perceived themselves to be powerless to share their concerns in case this led to punishment for them.

A more common perspective is that in order to promote safety, it is necessary to have a culture of ‘fair blame’ with openness and transparency. This means that people from anywhere in the system can flag up the risks without any fear of recrimination, and issues can be addressed before an incident occurs.

In terms of incident investigations, if all the people involved believe the process will be fair and trustworthy, and that they are safe to talk, it will be easier for an investigator to find out what really happened. This can enable collaboration to prevent recurrence, as well as support wider learning from the incident.

If those involved in an incident believe the only purpose of an investigation is to identify one person to blame in order to punish them, it is likely that all parties will seek to ensure that they cannot be found blameworthy. This may unnecessarily obscure the investigator from understanding the true course of events.

There may be incidents where someone is identified as being negligent or actively involved in malicious intent to harm others.